Need a Doctor in the LA/SD area who specializes in Endurance Athletes

Triathlon Forum
1

Title says it all but I know some of y’all will want more details so…

About 6 weeks ago I started having a few symptoms and I didn’t put them together at first. I was recovering very slowly from workouts and could no longer do back to back workouts like my schedule sometimes calls for. I’m a 5k runner so these would be things like 5x1M @5:30 w/ 60s rest on Wednesday followed by 6x1000m @ 3:10-12 w/ 400-600m recovery on Thursday.

I started noticing I was getting a few headaches and dizzy upon standing up kind of things eventually. Then the kicker came when I started to not be able to breathe very normally while running. Every now and then a breath would not feel full. In the middle of these symptoms though I did drop a 1:15:50 half during a tempo run but the breathing was becoming an issue during it.

Fast forward to like a week or two later I was racing a 5k and probably should’ve been around 15:40-15:50 and by 1.5m I was totally sucking for air. Big gasps that just felt empty. I decided to take a day off for the first time in a while and then on Monday I went for an 11 miler. I was doing like 6:50’s when around 5 miles I had to stop and just wait a minute to catch my breath. Each subsequent mile I had to stop again and catch my breath. That was 3 weeks ago, since then I’ve kind of had nonstop pressure on my chest and shortness of breath. I finally decided to run again friday but even 5m at 6:45 immediately made me sore for two days.

I finally saw a GP and had bloodwork done. Iron and what not was all good, thyroid was all good. But my EKG showed some heart block. Saw an electrophysiologist and did a stress test and I didn’t drop any beats though while running, only while very relaxed which he was okay with. My ECG also looked good.

So here I am no thyroid issues, no iron anemia, nothing crazy wrong with my heart yet i’ve shortness of breath, tight chest, I yawn incessantly, and my muscles get sore so damn easy. I mean, I can literally lay down and flex my muscles and it’ll go into a charlie horse.

I’m young, fit, eat well, do not drink (soda or alcohol), do not smoke, and I opted to get back on a multivitamin a week ago just to be safe and added magnesium to that.

Thus I’m in the market for a doctor in the LA/SD area (very willing to drive a good ways) who has worked with very fit endurance athletes who can shed more insight than a GP.

I’d strongly prefer the doctor to have experience with high mileage/quick athletes. Given there are so many pro triathletes/runners and college triathletes/runners around LA/SD, I figure there has got to be a doctor or five who will be able to help me.

Thank you so much!

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While I can’t say that he specializes in endurance athletes, my EP doc is Navinder Sawhney in San Diego. I REALLY like his calm demeanor, he is very thorough and attentive, unlike other cardio/EPs I’ve seen. He did my ablation for atrial fibrillation last year and is usually at his Palomar hospital office although he goes to Poway on Mondays. My wife would recommend Dr. Charles Athill with Sharp in San Diego - he is an EP specialist and did her pacemaker implant last year after Stephen Higgins at Scripps La Jolla botched her ablation resulting in complete heart block (so obviously, we’d recommend NOT going to him!). Dr. Athill is super conservative and also extremely thorough (his father died from complications from afib, so he takes it personally). He has also been in practice longer than Dr. Sawhney so has likely seen more cases and more variety.

John Rogers at Scripps Green Hospital is also a great guy (not EP specialty) that you’d probably like. Doug Gibson is the main EP guy at Scripps Green, and is not recommended by my cousin who operated with him on numerous occasions as a cardiac OR nurse.

Hope this helps.

3

Endurance athlete and unexplained SOB I think of a possible pulmonary embolism. I’m not nearly as fast as you but other than the muscle issues that was me 6 years ago. Could not get a full breath all the time. Felt like aomeone was squeezing the lungs. Went to 3 specialists over 6 weeks including a pulmonologist who all failed to dx it. Have them run a d dimer blood test as an initial screen. But I would not fuck around with SOB without a known cause.

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How is your heart rate during those episodes? I wonder if exercise induced asthma would explain it. LA is my home town I’ll see if any of my old training buddies know anyone.

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Endurance athlete and unexplained SOB I think of a possible pulmonary embolism. I’m not nearly as fast as you but other than the muscle issues that was me 6 years ago. Could not get a full breath all the time. Felt like aomeone was squeezing the lungs. Went to 3 specialists over 6 weeks including a pulmonologist who all failed to dx it. Have them run a d dimer blood test as an initial screen. But I would not fuck around with SOB without a known cause.

good call. also to OP did they run a CPK on you to check muscle enzymes? that doesn’t really fit with the PE picture but i didn’t sleep in a Holiday Inn last night (i think that’s how it goes?).

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Endurance athlete and unexplained SOB I think of a possible pulmonary embolism. I’m not nearly as fast as you but other than the muscle issues that was me 6 years ago. Could not get a full breath all the time. Felt like aomeone was squeezing the lungs. Went to 3 specialists over 6 weeks including a pulmonologist who all failed to dx it. Have them run a d dimer blood test as an initial screen. But I would not fuck around with SOB without a known cause.

+1. Not sure you need to see an EP or a sports medicine MD specifically. I would consider returning to your primary care doctor and seeing whether he has additional investigations, especially if that would mean you would be seen sooner. SOB is a common complaint and it doesn’t seem like it has been fully worked up. Are you tachycardic or wheezy during an episode? Leg swelling? Family history of clotting disorders? Did you have a chest x-ray? Has the SOB gotten worse? Is the pain reproducible by touching a part of your chest? etc etc. It would be reasonable to get more history, some more lab tests, a chest x-ray, and consider further testing or referrals. Sometimes a generalist is the best MD for a general complaint (and I say that as a specialist).

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Agree with the above; you should be checked for a pulmonary embolism. D-dimer would be a start, although further diagnostics are necessary. Be aware that doctors tend to blow off the possibility of blood clots in athletes, when in fact the risk seems to be raised. If you have any leg pain, especially calf, along with your shortness of breath, you need to really be insistent that you be checked for a DVT/PE ASAP. Unrelated to a potential clot (I think), did your blood work include sodium, potassium, and magnesium levels?

If you’re looking for a cardiologist, David Cannom in Los Angeles is really good and is known for his work with athletes. He’s been around a long time and really knows his stuff, and is on top of latest research and innovations. He would definitely know what to look for heart-wise; I suspect that he would also recognize the possibility of a PE, even though that’s not his specialty area.

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If you’re looking for a cardiologist, David Cannom in Los Angeles is really good and is known for his work with athletes. He’s been around a long time and really knows his stuff, and is on top of latest research and innovations. He would definitely know what to look for heart-wise; I suspect that he would also recognize the possibility of a PE, even though that’s not his specialty area. //

This is my doctor and he is very good with the heart stuff. And there are many possibilities, but you said you had some heart block, and that could be it. Most often when you go to get it checked, it will be fine, that was my experience. All your breathing difficulties could just be from going through the block during racing and training, that is what happens when your heart stops, you gasp for breath. Has nothing to do with your lungs, just the lack of oxygen getting to them. And it is not ;ike a heart attack or something you feel, in fact it is painless if electrical. that is what mine was, and i just thought i was getting sick or the flu. But luckily i used a HR monitor very regular, and i noticed very funny readings every time i felt funny, so went to the ER room. They could find nothing, then another night later rushed back in, and nothing again.

Not until i put on a 24 hour halter monitor did they find the long blocks i was having. Sometimes for 20 seconds. People usually pass out when it happens this long, but as endurance athletes, we walk around for a very long time before we actually pass out. Our brains are trained to go without oxygen a lot longer than the average person walking around, so we often take longer to get diagnosed with heart block. Once they read the monitor, it was emergency pacemaker surgery, they felt very stupid to have sent me home twice in my condition, 3rd degree heart block it was.

Try and get into see Dr Cannom, he is downtown LA at LA Cardiology. He is a very busy guy, as he travels and teaches a lot too. But there are some other very good docs there, some even very good runners and triathletes, so I trust them a lot more. Plus i have taught them a lot about this problem and its association with elite endurance athletes, so the have that knowledge from me being the guinea pig. I even put Greg Welch on to him during his problem time, but i think his insurance did not cover it with him, or some other problem. But he had a lot to say about the bad care he had gotten up til then from his other docs.

If it is indeed heart block, there are many ways you can proceed, and several will let you still race, even with a pacemaker(like i have). Get it sorted out and PM me if you have any other questions and concerns. It can be a scary time, but information can really make it go easier, wish I had someone to talk to when i went through all that crap. Could have saved me a few gray hairs, and many years of worry and inactivity.

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Was not expecting such well thought out answers (nothing against any of y’all!).

So let me expand upon a few of the questions.

My initial labs tested the following,

Iron and TIBC
Creatine Kinase,Total,Serum
Aldolase
Ferritin, Serum
CBC With Differential/Platelet
C-Reactive Protein, Quant
Comp. Metabolic Panel (14)
TSH reflex to T4F

Per my GP, the numbers for all of those came back good. Nothing in any of the tests were outside the normal ranges.

Starting from the first real episode of strong gasping during that 5k 23 days ago, the 11 miler two days later (21 days ago) was the worst thing to date workout wise. I felt like I just couldn’t continue to breath while I ran. Beginning that night immediately following the run began the constant pressure on my chest and shortness of breath. It set in during the 11 miler and has not left since. It’s been worse at times where I almost wanted to have panic attacks due to the SOB and then there have been days where it’s been better and I will feel like I can breathe freely most of the day. When it does get bad I try hard to relax physically and mentally and assure myself I’m breathing fine (even if i’m not, telling myself i’m not would cause me to panic). I would like to add though that I do not recall swelling or pain in the lower extremities, symptoms i’m assuming would be linked to DVT. I just remember that I started the 11 mile run feeling good and fresh so I decided press the pace a bit given that it was supposed to be an easier day and I suddenly found myself awfully short of breath.

I have run twice during all of this and that was this past friday and Saturday. Friday’s run was a 5.1 miler which I did around 6:45 pace. It left my calfs quite sore and I definitely felt tightness in the chest and SOB throughout the run.

Saturday I decided to run another 5 miler and this time fished out my HR monitor. I kept the run at an AHR of 160 and I was able to do 7:20 at that HR with 250’ of total climbing. The run felt a bit better than the day before but to be fair, Saturday/Sunday were to of my best breathing days to date. They preceded today which was not my worst breathing day but not my best either.

The muscle soreness has just continued to be a problem and the fact that as I type this I can lock a handful of muscles in my legs into charlie horses is a huge problem. It’s limiting my ability to really go hard.

My first EKG which was taken 18 days ago showed heart block while at rest. My EKG/Stress Test today showed no heart block while at elevated heart rates. But when I was resting and the doctor wasn’t in the room I spotted two heart blocks within like 5 beats of one another on the machine (i’m not a doctor but I can definitely spot a heart block occur when there’s a massive flat line from the time the upper chamber beats to the lower chamber beats or doesn’t beat at all). I mentioned those to the EP and he wasn’t overly concerned about them since I was very calm and resting. My resting heart rate at the time that occurred was 38. I assume it probably gets lower than that when I’m truly at rest and undisturbed and perhaps sleeping.

As I sit here and type this I have SOB and just yawned to increase the oxygen intake. It’s one of the sure fire ways I can relax is to force a yawn. I’ve NEVER yawned this much in my entire life. Whether I sleep 4 hours or 10 hours, I will wake up and just begin to yawn.

As for family history, my father’s ailments in life have only ever been the result of his athletic endeavours, my mother however has had numerous medical problems and has definitely had many blood clots although i’m unsure if they’re byproducts of medicines she’s been on for the numerous surgeries she’s had. I can ask her tomorrow but I do believe a few of them have occurred on their own out of the blue.

For now…

I continue to eat like a normal human being and try to keep it well rounded, I take a multivitamin every day alongside a magnesium supplement and two iron pills which get me to about 130 mg of elemental iron per day in supplements. I sleep roughly 6.5-8 hours/night and work behind a desk mostly.

So as for what y’all have said, it seems like it might be good to press my GP to take another blood sample and to the D-Dimer test and possibly a few others?

Also, I will look into the Cardiologist in Downtown LA, seems like he’s got a reputable clientele.

Thank you so much in advance, this has been extremely mentally tiring. We’re all type A athletes and so to be sidelined for 3 weeks has crushed me. I had plans to travel to Oregon to break my 5000 PR in August and that’s been nixed for now. Still have a half marathon planned in October but it’s quickly becoming something I may just trot through and not race at this point.

Thanks again!

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I’m not a doc and am admittedly particularly sensitive to them having had two episodes, and know nothing of heart blocks, but reading this post makes me think even more of a PE given my experience. It came and went. The only way I could get a full lung breath was to yawn. I had the typical strains and pulls we all get but they never found d a DVT related to my PEs. My stress test and scans were fine. My pulmonary function tests were normal, 02 sat was 98%. No calf redness/soreness.

I’m not an alarmist, but i lived with these symptoms for 6 weeks until I began experiencing severe pain below the ribcage, enough to drive myself to the er where they assumed it was pleurisy or exercised induced asthma but they ran a “let’s just run a d dimer before you leave” just to close thst loop. Rest is history. They admitted me for 3 or 4 days and the pain was nearly umbeaeable. Morphine did nothing. Because they took so long to diagnose i ended up with some lung damage which eventually healed. Not saying you should be going to the er tonight but you should be demanding an appt tomorrow to address this asap. The family history is another risk factor, as is ironically a low RHR, your heart simply does not beat with enough regularity to push blood pooling in extremities back to the heart

Hopefully it’s nothing serious

11

Thought y’all might like to see this. Snapped it while waiting for the doctor. You can see it fuzzily says “38” for my BPM and you can see Heart Block occur on the left and then a few beats later a pretty much Heart Block again. My EP apparently didn’t find this concerning? I still think it’s interesting regardless.

For those who don’t know what you’re looking at. Look at either the middle or bottom line (they’re probably different to a trained professional but the same for me). You see two good heart beats and then a big gap. What should happen is you get a little bump for your upper chamber beating, then a big bump for the lower chamber, then a medium bump for the recovery. So where I should’ve had a third beat, there’s a big delay between my upper chamber and my lower chamber firing. I then have two more good heart beats before my upper chamber fires and my lower chamber doesn’t fire at all, you see a small bump then medium bump as the heart recovers. Shortly thereafter there’s a small bump which is the upper chamber firing again and a long pause before the lower chamber fires off.

I’m surprised he didn’t find this weird because to me, a laymen, it looks like 3 beats out of five were no good which seems incredibly high. Who knows though, my degree is in economics?

http://i.imgur.com/OEGL7FL.jpg

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I would really call and schedule with Dr. Cannom ASAP. If he thinks you need to be assessed for a PE, he’ll do that. I have a friend who scheduled with Cannom late last week, also as a new patient, and is being seen today, so there’s a chance you can get in relatively quickly. Keep in close contact with your GP until you can get in.

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to add to the voices, my son had a 100% collapsed lung and was not SOB and his O2 sats were mid 90s (above 95).

also you might see if you can contact Dr. Larry Creshwell (damn i can never remember his name) but he is on ST and runs a blog. let me see if i can find it. athlete’s heart or something? http://www.athletesheart.org/

send him your ECG pic and see what he says. PE is not to be messed with. if your mom had some blood clot issues AND you have a PE you need to insist on a coagulable workup as you may have a hereditary condition (Iirc) like factor V or one of those. (course then you’ll be on thinners life long but better than dying from a PE. because they are Not to be dismissed). good luck and keep us updated!

also were you definitively dx’d with hb? because that EKG doesn’t look to me like HB (but what do I know).

also you’re not taking any statins, right? those would cause muscle soreness.

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Ya, you should go see Cannom, you can use my name if you want, we are quite friendly, and he has enjoyed working on me. Some things you left out that are very important, magnesium, sodium, and potassium levels right now. Do you drink a lot of coffee, sodas, caffeine drinks? Do you drink alcohol at night, and if so, how much?

And what is your normal stress level? Of course now you are making it worse with all your worry, and that is normal. When i knew what was going on, my anxiety went through the roof, and my symptoms quadrupled just from that. I would get that 24 hour halter monitor, do your run in it, and write down what time of day you experience your symptoms so they can go back and see “exactly” what was going on with your heart at that particular time. Like i said, going into the ER or hospital for random checks really produces nothing, and even when it does like in your example, they sluff it off. It is normal for folks to have a couple hundred PVC’s a day, more when you get anxious. So that is probably what they thought you were having. And in low levels of mag and sodium, you will have a lot more issues, that is what triggered mine into going haywire. that along with doing a race in that state. So get those checked, or go back and look where they were.

They will often say everything was normal, but they neglect to tell you if it was low normal. For instance, normal mag could be 2.7 to 3.8. If you are at 2.7 or so, it just spits out as normal, but really you are borderline low. And one good workout and you could be 2.3. Same goes with sodium and potassium, look to see where you are on the spectrum, because these minerals can have devastating affects on your heart rhythm.

Good luck, and stop working out and figure this thing out before going forward. It is ok to take time off, either a little now, or a lot later, usually how the choice goes.

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Whatever happens, please check back in and let us know you’re OK. It sort of freaks me out when people post symptoms and get advice re what might be at issue and then they don’t post the resolution (usually I suspect because it turns out it’s nothing).

Good luck with it

16

So I went back and looked at all the lab test and the sodium, potassium, etc we’re all mid range, not towards the lower end. I’ll still continue to supplement with a multi and magnesium pills just to be sure.

I also called my PCP and have requested that they put in an order for a D-Dimer to hopefully rule out the PE or DVT if it comes back negative or perhaps gives a good heads up if it comes back positive.

If it comes back negative I will surely reach out to Dr Connam but it will have to hold until after the Special Olympics World Games as I am heavily involved in that event for 18 days.

I will definitely report back though on this thread to close the loop.

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Hey - I’m an Emergency Room resident physician - so I have some experience with heart stuff, but I’ve just finished med school and started residency training. (I also raced tri at a fairly high level a long time ago).

Looking at that short rhythm strip it looks like you have a AV block - I can’t really tell from the strip but it looks like a AV type 1 - but it doesn’t look classic to me (gradually prolonging P wave - and then a dropped QRS). Reading your story i’m concerned and I would be getting a fairly emergent consultation by a cardiologist to rule out both PE as well as AV type 2 / 3 block (those kind are really bad)… I know you said the EP? dr wasn’t concerned, but given you’re symptoms and that short ECG I’d again strongly recommend emergent follow up.

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Hey - I’m an Emergency Room resident physician - so I have some experience with heart stuff, but I’ve just finished med school and started residency training. (I also raced tri at a fairly high level a long time ago).

Looking at that short rhythm strip it looks like you have a AV block - I can’t really tell from the strip but it looks like a AV type 1 - but it doesn’t look classic to me (gradually prolonging P wave - and then a dropped QRS). Reading your story i’m concerned and I would be getting a fairly emergent consultation by a cardiologist to rule out both PE as well as AV type 2 / 3 block (those kind are really bad)… I know you said the EP? dr wasn’t concerned, but given you’re symptoms and that short ECG I’d again strongly recommend emergent follow up.

huh? It is hard to tell from his photo as it is too poor of resolution to make out the P waves. Also your terminology of the AV block types is confusing. If it’s 1st degree AV block, there is long PR but all atrial impulses are conducted via AV node. 2nd degree type 1 is Wenckebach and benign. Both 1st degree and Wenckebach are both extremely common in athletes with high vagal tone. 2nd degree type 2 is an emergency because it can progress to 3rd degree which is also an emergency because it is complete heart block. However, I have heard at least one EP say that 2nd degree type 2 and possibly even complete heart block AT REST in a highly conditioned athlete who is asymptomatic is not an indication for a pacemaker. OP is not asymptomatic, obviously, so if he had 2nd degree type 2 or 3rd degree it would possibly be an indication. To OP, I am guessing that the reason your EP was not concerned about those dropped beats is that you have one of the two benign types of heart block as mentioned above. The idea for a Holter may be reasonable, to see if you can speed up adequately or if you are having bradycardia coincident with your episodes. I am assuming though that that was done at least for 10-15 minutes during your treadmill test and was normal.

I do agree, however, that you might consider pursuing a more expeditious workup for PE.

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Agree - I can’t really tell which 2nd degree AV block it is due to the picture resolution - because I can’t see the P waves. The QRS look in the middle rhythm stop to be gradually elongating (which suggests a type 1), but then he has that odd morphology where he misses the ventricular depolarization but still has what looks like a small T wave? (I really would love a full 12 lead).

As I said, if a cardiologist wasn’t concerned then its unlikely a type 2, but if that pictures showed up, I wouldn’t discharge him until a PE and type 2 block (or even a slow a fib) had been ruled out by cardiology.

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Agree - I can’t really tell which 2nd degree AV block it is due to the picture resolution - because I can’t see the P waves. The QRS look in the middle rhythm stop to be gradually elongating (which suggests a type 1), but then he has that odd morphology where he misses the ventricular depolarization but still has what looks like a small T wave? (I really would love a full 12 lead).

As I said, if a cardiologist wasn’t concerned then its unlikely a type 2, but if that pictures showed up, I wouldn’t discharge him until a PE and type 2 block (or even a slow a fib) had been ruled out by cardiology.

this, which is why i’m somewhat discounting the docs assessment. SOB and abnormal EKG along with (albeit athletic heart) brady and I’m going to probe a little more, no?